Advanced Life Suppor..


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Advanced Life Suppor..

  1. 1. Advanced Life Support Protocol Update 2006
  2. 2. Introduction <ul><li>Developed by the REMAC Protocol Subcommittee </li></ul><ul><li>Derived from the SEMAC ALS Protocol Template </li></ul><ul><li>Distributed to all regional ALS agencies, Hospitals, County EMS Coordinators for comment </li></ul><ul><li>Approved by the SEMAC/SEMSCO and REMAC/REMSCO </li></ul>
  3. 3. Format <ul><li>Modular Format: </li></ul><ul><ul><li>Operations </li></ul></ul><ul><ul><li>Adult Medical </li></ul></ul><ul><ul><li>Adult Trauma </li></ul></ul><ul><ul><li>Special Considerations </li></ul></ul><ul><ul><li>Pediatric Medical </li></ul></ul><ul><ul><li>Pediatric Trauma </li></ul></ul><ul><ul><li>Appendix </li></ul></ul>Together, the seven separate sections make up the Regional ALS Protocol
  4. 4. General Operating Procedures <ul><li>Introduction </li></ul><ul><li>EMT-Intermediate/Critical Care Program </li></ul><ul><li>Clinical Judgment </li></ul><ul><li>Interpretation of Protocols </li></ul><ul><li>Medical Control </li></ul><ul><li>Medical Authority at the Scene </li></ul><ul><li>Communications </li></ul><ul><li>Communications Failure </li></ul><ul><li>Transfer of Care </li></ul><ul><li>Patients Who Refuse Care </li></ul><ul><li>Initiation and Termination of CPR Including DNR </li></ul>Table of Contents
  5. 5. General Operating Procedures <ul><li>Pediatric Definitions </li></ul><ul><li>Procedures </li></ul><ul><li>Medications </li></ul><ul><li>Equipment </li></ul><ul><li>Destination Decision </li></ul><ul><li>Ambulance Diversion </li></ul><ul><li>Inter-Facility Transfers </li></ul><ul><li>Protocol Exceptions </li></ul><ul><li>Record Keeping </li></ul><ul><li>EMS Complaint/Concern Procedures </li></ul><ul><li>EMS Disciplinary Procedures </li></ul><ul><li>Protocol Changes </li></ul>Table of Contents
  6. 6. Introduction <ul><li>This manual represents the minimum standard of care for provision of pre-hospital advanced levels of care in the Hudson Valley Region. </li></ul><ul><li>The Regional Advanced Life Support (ALS) system incorporates three different tiers of ALS care which includes EMT-I, EMT-CC, and EMT-P levels of personnel and services. </li></ul>
  7. 7. EMT-I/CC Program <ul><li>The EMT-Intermediate/EMT-Critical Care (EMT-I/EMT-CC) program is designed for use only as an adjunct within an established EMT-P (Paramedic) system. </li></ul><ul><li>Requires an EMT-P (Paramedic) two-tiered priority response with simultaneous dispatch </li></ul>
  8. 8. Clinical Judgment: <ul><li>Guidelines which should be used in conjunction with good clinical judgment. </li></ul><ul><li>In situations where there is no existing protocol and a clear need for ALS exists, the ALS provider shall initiate Initial Advanced Life Support Care, Protocol ACP-1 and contact Medical Control </li></ul>
  9. 9. Interpretation of Protocols <ul><li>NYS BLS Protocols must be initiated, in conjunction with the HVREMSCO Advanced Life Support Protocols. </li></ul><ul><li>ALS personnel will initiate Initial Advanced Life Support Care, Protocol ACP-1, for every ALS patient </li></ul>
  10. 10. Interpretation of Protocols <ul><li>In each protocol, for every standing order and medical control option, there is indication as to which level of provider may initiate that order. </li></ul><ul><li>EXAMPLE: </li></ul>I/CC/P <ul><li>Airway control procedures </li></ul><ul><li>If patient is intubated, secondary confirmation must be performed, at a minimum, with End-tidal CO2 monitoring and Pulse Oximetry. Continuous CO2 monitoring is recommended. </li></ul><ul><li>Refer to appropriate protocol for further assessment and treatment. </li></ul>
  11. 11. Interpretation of Protocols <ul><li>Some protocols are designed to have numbered standing orders only; other protocols have numbered standing orders and medical control options. </li></ul><ul><li>Standing orders may be initiated prior to contacting Medical Control, and MUST be performed in numerical sequence. </li></ul><ul><li>If there is clinical improvement, further standing orders may be withheld based upon the ALS Provider’s clinical judgment. </li></ul>
  12. 12. Interpretation of Protocols <ul><li>Medical control options may not be initiated until ordered by Medical Control. Medical Control will sequence medical control options. </li></ul><ul><li>Example: </li></ul>Medical Control options Diazepam 5-10mg IVPMorphine Sulfate 2-10mg IVP Midazolam 0.5-2mg Slow IVP Lidocaine 1.0-1.5mg/kg slow IVP (as appropriate for increased intracranial pressure) EMT-I’s Stop Here. EMT-CC/P’s Contact Medical Control.
  13. 13. Interpretation of Protocols <ul><li>Additional information pertinent to the protocol has been included in separate sections entitled “Considerations”. </li></ul><ul><li>Example: </li></ul><ul><li>Considerations </li></ul><ul><li>Prior to nasotracheal intubation, consider the administration of Phenylephrine HCl 1% Nasal Spray. If utilized, administer 2 sprays in the selected nostril. </li></ul><ul><li>RSI Credentialed Paramedics may refer to Medication Facilitated/Rapid Sequence Intubation Protocol SCP-5 as appropriate. </li></ul>
  14. 14. Interpretation of Protocols <ul><li>It is understood that a patient’s clinical presentation may require more than one protocol. </li></ul><ul><li>In such cases, the patient’s most emergent clinical problem should be treated as the priority. </li></ul><ul><li>Implement the standing orders in the new protocol without exceeding the maximum recommended medication dosages and contact Medical Control as indicated. </li></ul>
  15. 15. Medical Control <ul><li>Standing Orders </li></ul><ul><li>Medical Control Options </li></ul><ul><li>“Medical Control Practitioner” means a HVREMAC credentialed Physician or Physician’s Assistant . </li></ul>
  16. 16. Medical Authority at a Scene <ul><li>Only a Medical Control Practitioner may relinquish Medical Control, </li></ul><ul><ul><li>and only to an identified physician at a scene. </li></ul></ul><ul><ul><li>may allow ALS providers to follow orders from the physician at a scene, provided such orders are included within the Regional ALS Protocols. </li></ul></ul>
  17. 17. Medical Authority at a Scene <ul><li>Orders given by an on scene physician that are not within established HVREMSCO protocols require: </li></ul><ul><ul><li>That the on scene physician implements the order. </li></ul></ul><ul><ul><li>That the on scene physician utilizes his/her own drugs and equipment. </li></ul></ul><ul><ul><li>That the on scene physician accompanies the patient to hospital. </li></ul></ul><ul><ul><li>The on scene physician who accepts Medical Control will complete and sign the &quot;Physician Release Form&quot; </li></ul></ul>
  18. 18. Communications <ul><li>ALS Providers may contact Medical Control at any time. </li></ul><ul><li>The ALS Provider must contact the Medical Control Facility upon completion of standing orders, and whenever there is a patient who requires ALS services, but refuses treatment or transport. </li></ul>
  19. 19. Communications <ul><li>When patients are transported to a hospital not providing the Medical Control </li></ul><ul><ul><li>The MC Practitioner providing the order will notify the clinical practitioner in charge of the Receiving Emergency Department </li></ul></ul><ul><li>If on scene >20 min. document circumstances </li></ul>
  20. 20. Communication Failure <ul><li>Complete appropriate standing orders and initiate transport. </li></ul><ul><li>Attempt voice contact with any available Regional MC Facility. </li></ul><ul><li>After call, advise Medical Control and document circumstances </li></ul>
  21. 21. Transfer of Care <ul><li>ALS Providers may transfer care of a patient to another provider within the following provisions: </li></ul><ul><li>1. To an equal or higher level of care provider: </li></ul><ul><ul><li>When transport is by helicopter critical care team. </li></ul></ul><ul><ul><li>When transport is by another provider/service with the same level of training. </li></ul></ul><ul><ul><li>When patient is turned over to an appropriate receiving facility. </li></ul></ul><ul><li>2. To an equal or lower level of care provider: </li></ul><ul><ul><li>When the ALS Provider at the scene recognizes that there is no indication for ALS intervention. </li></ul></ul><ul><ul><li>When ALS capabilities are exceeded (ex. MCI) and patient is triaged to other ALS or BLS services. </li></ul></ul><ul><ul><li>When a coroner or other appropriate agency takes custody. </li></ul></ul>
  22. 22. Patients Who Refuse Care <ul><li>When a patient or legal guardian/proxy refuses treatment or transport: </li></ul><ul><li>Refer to New York State Department of Health, Bureau of EMS Basic Life Support Protocol SC-5 “Refusing Medical Aid (RMA)”; </li></ul><ul><li>Communicate with Medical Control if ALS is indicated. </li></ul>
  23. 23. Initiation and Termination of CPR including Do Not Resuscitate (DNR) <ul><li>The only exceptions to initiating CPR are: </li></ul><ul><li>For any patient originating from an Article 28 facility (hospital or nursing facility) when written DNR orders signed by a physician are presented ; </li></ul><ul><li>For any patient NOT originating from an Article 28 Facility (hospital or nursing facility) when a non-hospital DNR order is presented on the standard Department of Health form (DOH-3474) or when the standard Department of Health DNR bracelet is found on the patient’s body; </li></ul><ul><li>In cases of obvious death such as rigor mortis, decomposition, extreme dependant lividity, or mortal injuries such as decapitation. </li></ul>
  24. 24. Initiation and Termination of CPR including Do Not Resuscitate (DNR) <ul><li>Once CPR is initiated by a CFR, EMT or AEMT it must be continued until one of the following occurs: </li></ul><ul><li>Effective spontaneous circulation has been restored; </li></ul><ul><li>Resuscitative efforts have been transferred to another appropriately trained individual who continues CPR and other basic life support measures; </li></ul><ul><li>A Medical Control Practitioner agrees to relinquish Medical Control to an on-scene physician who assumes responsibility for the care of the patient; </li></ul><ul><li>A Medical Control Practitioner orders termination of CPR (by radio, telephone, or other communication means); </li></ul><ul><li>Care of the patient is transferred to hospital staff assigned responsibilities for emergency care; </li></ul><ul><li>A valid DNR is presented; </li></ul><ul><li>The CFR, EMT or AEMT is exhausted and physically unable to continue resuscitation. </li></ul>
  25. 25. Initiation and Termination of CPR including Do Not Resuscitate (DNR) <ul><li>If the decision is made to terminate CPR, the patient must still be transported if ; </li></ul><ul><ul><ul><ul><li>Arrest is in a public place </li></ul></ul></ul></ul><ul><ul><ul><ul><li>An environmental situation not conducive to termination exists </li></ul></ul></ul></ul><ul><ul><ul><ul><li>No police agency or coroner is present </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Communication failure occurred </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Asystole developed after the arrival of EMS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inadequate IV access or airway control was obtained . </li></ul></ul></ul></ul><ul><li>If decision is made not to transport, the ALS provider will leave all tubes and lines in place. </li></ul>
  26. 26. Pediatric Definitions <ul><li>A pediatric patient is any patient who is less than eighteen (18) years old. </li></ul><ul><li>The term “infant” refers to pediatric patients less than 1 year old. </li></ul><ul><li>The term “neonate” refers to pediatric patients in the first minutes to hours immediately after birth. </li></ul><ul><li>For the purposes of CPR and AED a child will be considered eight (8) years of age or less. </li></ul>
  27. 27. Procedures <ul><li>New Section (specifies various procedures) </li></ul><ul><ul><li>Biphasic defibrillation is an acceptable option if used according to the specific manufacturer’s instructions. </li></ul></ul><ul><ul><li>12 Lead ECG implementation strongly supported by the HVREMAC </li></ul></ul><ul><ul><li>EMT-I services are required to utilize Automated External Defibrillators. </li></ul></ul>
  28. 28. Medications/Equipment <ul><li>Agencies will be required to stock each ALS unit and maintain stock levels according to the minimum guidelines as set forth in the medication and equipment lists in the appendix. </li></ul>
  29. 29. Inter-Facility Transfers <ul><li>Patient care is the direct responsibility of the referring hospital and physician for all inter-facility transfer of patients. </li></ul>
  30. 30. Inter-Facility Transfers <ul><ul><li>Patients name; </li></ul></ul><ul><ul><li>Diagnosed condition of the patient; </li></ul></ul><ul><ul><li>Any treatment and any medication administered to the patient; </li></ul></ul><ul><ul><li>Name of physician ordering transfer; </li></ul></ul><ul><ul><li>Name of hospital from which the patient is being transferred; </li></ul></ul><ul><ul><li>Name of the physician(s) who is or are willing and authorized to receive the patient at the new location; </li></ul></ul><ul><ul><li>Name of hospital or other facility that is to receive the patient; </li></ul></ul><ul><ul><li>Date and time of transfer </li></ul></ul><ul><ul><li>Signature of the physician ordering the transfer. </li></ul></ul>Pre-hospital emergency personnel must insure that prior to initiating the patient transfer, they are supplied with written documentation of at least the following information:
  31. 31. Inter-Facility Transfers <ul><li>Pre-hospital emergency personnel must insure that prior to initiating the patient transfer, they are supplied with written documentation of at least the following information: </li></ul><ul><li>Obtain written medical orders that do not exceed their level of medical training; </li></ul><ul><li>Confirm that the receiving facility has agreed to accept the patient in transfer; </li></ul><ul><li>Are supplied with appropriate copies of the patient’s medical records, including radiographs; </li></ul><ul><li>Are utilizing the appropriate equipment needed to transfer the patient; </li></ul><ul><li>Verify that the patient has been stabilized to the fullest extent capable by the referring hospital prior to transfer. </li></ul>
  32. 32. Inter-Facility Transfers <ul><li>If a patient’s condition becomes critical during an inter-facility transport HVREMAC credentialed personnel shall utilize the ALS protocols in conjunction with the NYS BLS protocols provided Medical Control is contacted ASAP </li></ul>
  33. 33. Protocol Exceptions <ul><li>While acting in a setting which falls beyond the scope of the Regional ALS Protocols, no ALS Provider shall be faulted or suffer punitive action for: </li></ul><ul><ul><li>following on‑line Medical Control orders, provided the orders are within the ALS Provider’s standard of care and scope of training ; </li></ul></ul><ul><ul><li>for refusing to follow an order which the provider believes to increase risk to the patient; </li></ul></ul><ul><ul><li>for refusing to perform a procedure which is beyond the ALS Provider’s scope of training or expertise. </li></ul></ul>
  34. 34. <ul><li>This section is not intended by the HVREMAC as a means for field providers and Medical Control representatives to circumvent procedures or training requirements specifically addressed by the protocols. </li></ul>Protocol Exceptions
  35. 35. Record Keeping <ul><li>ALS providers must document all ALS procedures performed on an appropriate PCR addendum (ex. PCR Continuation Form or other form approved by the HVREMSCO to be used in place of a PCR Continuation Form). </li></ul>
  36. 36. Record Keeping <ul><li>ALS Providers must complete a PCR (and when appropriate, a PCR addendum) immediately following a call, and a (Physician, Physician’s Assistant, or Nurse Practitioner, as appropriate) from the Receiving Hospital ED must also sign the ALS PCR or PCR addendum . </li></ul>
  37. 37. Record Keeping <ul><li>In cases where patients are transported to a hospital not providing the Medical Control for the transport, the ALS provider will </li></ul><ul><ul><li>Document on a PCR addendum the name of the Medical Control Practitioner and Medical Control Facility as well as the time of communication and all Medical Control orders received or denied. </li></ul></ul><ul><ul><li>The ALS Provider will have the PCR addendum signed by the clinical practitioner designated as in charge of the Receiving Hospital ED. </li></ul></ul>
  38. 38. Record Keeping <ul><li>All online medical control orders must be documented on a PCR addendum and must be authorized by a Medical Control Practitioner either by verbal authorization to the clinical practitioner designated as in charge of the Receiving Hospital ED ( when the patient is transported to a hospital not providing Medical Control ) or by written authorization ( when the patient is transported to the hospital providing Medical Control ). </li></ul>
  39. 39. Record Keeping <ul><li>The ALS provider MUST NOT leave the hospital until a completed PCR is provided to the appropriate hospital staff 1 </li></ul>1 NYS DOH Policy Statement 02-05
  40. 40. EMS Complaint / Concern Procedures <ul><li>Note: The NYS DOH, Bureau of EMS mandates specific incident reporting responsibilities and requirements for all EMS services. Mandatory reporting of incidents must be performed as indicated in: </li></ul><ul><ul><li>NY State EMS Code, Part 800, Section 21(q) 1-5 and Section 21(r), Part 80, 80.136 (k), NYS DOH, Bureau of EMS Policy Statement 98-11, and any other NYS DOH Policies and Procedures . </li></ul></ul>
  41. 41. EMS Disciplinary Procedures <ul><li>The Evaluation Committee is a sub‑committee of the Regional Medical Advisory Committee (REMAC). The Evaluation Committee consists of seven (7) members as follows: </li></ul><ul><li>Chairman of the Evaluation Committee </li></ul><ul><li>Chairman of the HVREMAC </li></ul><ul><li>Regional Medical Director </li></ul><ul><li>Regional Executive Director </li></ul><ul><li>Regional Quality Improvement Coordinator </li></ul><ul><li>Two EMS Providers </li></ul><ul><li>No member of the field unit or institution involved in the complaint shall be appointed to the Evaluation Committee. </li></ul>
  42. 42. No Changes <ul><li>Ambulance Diversion </li></ul><ul><li>Destination Decision </li></ul><ul><li>Protocol Changes </li></ul>
  43. 43. Protocol Format Changes <ul><li>Considerations Boxes </li></ul><ul><ul><li>May preface the clinical steps of the protocol </li></ul></ul><ul><ul><li>May also be found within the protocol’s clinical steps when the Level of Care changes (Paramedic considerations maybe different from those of a Critical Care Technician) </li></ul></ul><ul><ul><li>May also be found at the end of the protocol’s clinical steps </li></ul></ul>
  44. 44. Protocol Format Changes <ul><li>Medical Control Options </li></ul><ul><ul><li>Are found at the end of the clinical steps for a given level of care. </li></ul></ul><ul><ul><li>May also be found at the end of the protocol’s clinical steps </li></ul></ul>
  45. 45. ALS Care Protocol-1 Initial ALS Care <ul><li>“ This protocol is to be implemented in conjunction with the New York State Basic Life Support Adult and Pediatric Treatment Protocols for every patient that the ALS provider determines to require pre-hospital ALS care.” </li></ul><ul><li>Replaces Adult and Pediatric “ Routine Medical Care ” Protocol </li></ul><ul><li>Incorporates NYS BLS Protocol “ General Approach to Patient Care” as well as ALS procedures </li></ul>
  47. 47. What’s New? Adult Medical Protocols <ul><li>Lorazepam, Metoprolol, and Promethazine Hydrochloride were added to the formulary </li></ul><ul><li>Overdose and Toxic Exposure separated into two distinct protocols. </li></ul><ul><li>Two new protocols added: </li></ul><ul><ul><li>Abdominal Pain </li></ul></ul><ul><ul><li>Suspected Stroke </li></ul></ul>
  49. 49. What’s New? Adult Trauma <ul><li>New Protocols include: </li></ul><ul><ul><li>Major Trauma </li></ul></ul><ul><ul><li>Major Trauma Transport </li></ul></ul><ul><ul><li>High Risk Patient </li></ul></ul>
  51. 51. What’s New Special Considerations <ul><li>The following protocols have been moved into the Special Considerations section: </li></ul><ul><ul><li>Rapid Sequence Intubation </li></ul></ul><ul><ul><li>Child Birth/Precipitous Delivery </li></ul></ul><ul><ul><li>Pain Management/Analgesia </li></ul></ul><ul><ul><li>Toxemia of Pregnancy </li></ul></ul><ul><ul><li>Neonatal Resuscitation </li></ul></ul><ul><li>New Protocols in this section include: </li></ul><ul><ul><li>Mark I kit use </li></ul></ul><ul><ul><li>Emergency Incident REHAB </li></ul></ul>
  53. 53. What’s New Pediatric Medical Protocols <ul><li>Abdominal Pain has been added as a new protocol to this section </li></ul><ul><li>Toxic Exposure and Overdose were separated into two distinct protocols </li></ul>
  55. 55. What’s New? Pediatric Trauma Protocols <ul><li>New Protocols in this section include: </li></ul><ul><ul><li>Major Trauma </li></ul></ul><ul><ul><li>High Risk Patients </li></ul></ul><ul><ul><li>Traumatic/Hypovolemic Shock </li></ul></ul><ul><ul><li>Tension Pneumothorax </li></ul></ul><ul><ul><li>Head Trauma </li></ul></ul><ul><ul><li>Burns </li></ul></ul><ul><ul><li>Major Trauma Transport </li></ul></ul>
  56. 56. What’s New? <ul><li>Each of the five clinical sections of the protocols includes reference charts (such as GCS and Burn Charts) which may be helpful to ALS providers in the field. </li></ul>
  58. 58. Appendices <ul><li>Include: </li></ul><ul><ul><li>Regional Helicopter Utilization Guidelines </li></ul></ul><ul><ul><li>Regional Hospital Information </li></ul></ul><ul><ul><li>Location Codes </li></ul></ul><ul><ul><li>Physician Release Form </li></ul></ul><ul><ul><li>Equipment List </li></ul></ul><ul><ul><li>Medication List </li></ul></ul><ul><ul><li>Drug Formulary </li></ul></ul>
  59. 59. Formulary Changes <ul><li>Additions to the formulary include: </li></ul><ul><ul><li>Lorazepam </li></ul></ul><ul><ul><li>Metoprolol </li></ul></ul><ul><ul><li>Promethazine HCl </li></ul></ul><ul><li>The following have been removed from the formulary: </li></ul><ul><ul><li>Oxytocin </li></ul></ul><ul><ul><li>Verapamil </li></ul></ul>